[Association of maternal isolated thyroid peroxidase antibody positive in the first trimester with fetal growth].

OBJECTIVE: To investigate the association of isolated thyroid peroxidase antibody (TPOAb) positive in the first trimester with fetal growth. METHODS: A total of 16 446 pregnant women were included in the birth cohort study, whose last menstrual period was between May 2016 and April 2019 and with singleton pregnancy. Maternal serum samples were collected when they firstly came for prenatal care in the first trimester. The pregnant women were consecutively seen and followed in the hospital and the information of pregnant women was extracted from the electronic medical information system. The pregnant women were divided into isolated TPOAb positive group (n=1 654) and euthyroid group (n=14 792). Three fetal ultrasound examinations were scheduled during the routine prenatal visits at the hospital and were performed by trained sonographers. All fetal growth indicators were quantified as gestational age- and gender- adjusted standard deviation score (Z-score) using the generalized additive models for location, scale and shape (GAMLSS). Fetal growth indicators included estimated fetal weight (EFW), abdominal circumference (AC), biparietal diameter (BPD), femur length (FL) and head circumference (HC). Fetal growth restriction (FGR) was defined as AC or EFW Z-score＜3rd centile based on clinical consensus. Generalized estimating equation (GEE) analysis was applied to assess the association of maternal isolated TPOAb positive with fetal growth. The generalized linear model was further used to analyze the association between isolated TPOAb positive and fetal growth indicator at different gestational ages when the fetal growth indicator was significantly associated with isolated TPOAb positive in the GEE mo-del. RESULTS: The median gestational age at three ultrasound measurements was 23.6 (23.3, 24.1), 30.3 (29.7, 30.9), 37.3 (37.0, 37.7) weeks, respectively. The BPD Z-score was higher in isolated TPOAb positive women, compared with the euthyroid pregnant women after adjustment (ß=0.057, 95%CI: 0.014-0.100, P=0.009). The generalized linear model showed the BPD Z-score was higher in the isolated TPOAb positive women at the end of 21-25 weeks (ß=0.052, 95%CI: 0.001-0.103, P=0.044), 29-32 weeks (ß=0.055, 95%CI: 0.004-0.107, P=0.035) and 36-40 weeks (ß=0.068, 95%CI: 0.011-0.125, P=0.020), compared with the euthyroid pregnant women. There was no difference in other fetal growth indicators (EFW, AC, FL and HC) and FGR between the isolated TPOAb positive and euthyroid pregnant women. CONCLUSION: The BPD Z-score was slightly increased in the isolated TPOAb positive pregnant women in the first trimester, while other fetal growth indicators were not changed. The reproducibility and practical significance of this result need to be confirmed.

A Patient-Centred Approach to Early Pregnancy Loss: The First 18 Months of a Canadian Outpatient Program for Early Pregnancy Loss (OPEL).

OBJECTIVE: Manual vacuum aspiration is a safe surgical option for the management of early pregnancy loss. To provide rapid, patient-centred access to MVA, an Outpatient Program for Early pregnancy Loss ("OPEL") was established at our institution. Objectives were to (1) assess complete uterine evacuation rates; (2) assess complication rates, and (3) assess patient satisfaction with the program. METHODS: With REB approval, a retrospective study was performed. Patient records from the first 18 months of OPEL (November 2015 to April 2017) were reviewed. Anonymous patient satisfaction questionnaires were completed immediately post-procedure. RESULTS: A total of 162 patients received treatment. Missed abortions accounted for 94 cases (58%). Median delay from referral to clinic appointment was 4.0 (interquartile range [IQR] 2.0-6.0) days. Average length of stay was 3.0 (IQR 2.5-3.0) hours. Efficacy of the procedure was 95.1%. Complication rate (immediate and delayed) was 14.2% and included intraoperative hemorrhage (3.1%; 5/162), Asherman's syndrome (1.9%; 3/162), retained products of conception requiring further treatment (4.9%; 8/162), and postoperative infection requiring antibiotic therapy (1.9%; 3/162). A total of 151 post-procedure satisfaction surveys were completed (93%); 100% agreed/strongly agreed that the nursing staff and physicians provided professional and compassionate care; 99.3% were satisfied with their care overall. Qualitative feedback was positive. CONCLUSION: Pregnant patients experiencing early pregnancy loss benefit from safe, timely, accessible, patient-centred care in the outpatient OPEL program. Similar models should be adopted nationally to ensure women experiencing this common pregnancy complication receive safe and compassionate care.

Committee Opinion No. 418: The Complete 11-14 Week Prenatal Sonographic Examination.

OBJECTIVE: Sonography during the first trimester provides an opportunity to assess a pregnancy in its early stage. This document provides an opinion about the implementation and content of prenatal sonographic examinations at 11-14 weeks gestation in Canada. TARGET POPULATION: Pregnant women at 11-14 weeks gestation. BENEFITS, HARMS, AND COSTS: The 11-14 week prenatal sonographic examination can provide important information that may contribute to pregnancy management. It can be used to confirm viability, establish gestational age, determine the number of fetuses, assess the adnexa/ovaries, and, in a multiple pregnancy, assess chorionicity and amnionicity. Scanning also offers an opportunity to detect fetal abnormalities and perform aneuploidy screening by measuring the nuchal translucency thickness. It may be valuable in screening for preeclampsia and other obstetrical disorders (by combining uterine artery Doppler scanning with other bio-clinical markers) and for invasive placentation. There are no physical harms to mother or fetus from offering a routine 11-14 week prenatal sonographic examination, and there are no extra costs for patients. EVIDENCE: Articles related to routine 11-14 week prenatal sonography were identified in a search of EMBASE and MEDLINE using the search terms first trimester ultrasound, nuchal translucency, and 11-14 week ultrasound. The search included all articles published on the topic until May 2019. Abstracts were reviewed by one author, and articles deemed relevant were then reviewed in full to determine whether to include them in the study. Articles that were not in English and articles that did not pertain to 11-14 week prenatal sonography were excluded. INTENDED AUDIENCE: This document is intended for sonographers, midwives, family physicians, obstetricians, and maternal-fetal medicine specialists.

Does Excess First- or Second-Trimester Weight Gain Predict Excess Total Gestational Weight Gain? A Multicentre Prospective Cohort Study.

OBJECTIVES: Early excess gestational weight gain (GWG) has been examined as a predictor of total excess GWG in a few international studies; however, Canadian data are lacking. We sought to determine whether early (first- and second-trimester) excess GWG predicted total excess GWG. METHODS: We conducted an a priori planned secondary analysis of a multicentre prospective study of English-speaking Ontario women with a singleton pregnancy between 80 and 206 weeks gestation. Our primary outcome was prediction of total excess GWG. We calculated the sensitivity, specificity, predictive values, and likelihood ratios, by body mass index (BMI), for excess first- and second-trimester GWG. RESULTS: Of the 970 women who met the inclusion criteria, 387 and 754, had first- and second-trimester weights recorded in their antenatal record, respectively. For normal, overweight, and obese women, the sensitivity of excess first-trimester GWG for total excess gain was 66%, 68%, and 65%, respectively; and the specificity was 48%, 43%, and 36%, respectively. The sensitivity of excess second-trimester GWG for total excess gain for normal weight, overweight, and obese women was higher, at 92%, 96%, and 95%, respectively; while the specificity was low at 31%, 16%, and 29%, respectively. CONCLUSION: In the first known Canadian study of early excess weight gain as the predictor of total GWG, we found that excess first-trimester GWG did not predict total excess GWG, but that the sensitivity of excess second-trimester GWG for excess total GWG was high across BMI categories.

Evaluation of embryonic posture using four-dimensional ultrasound and virtual reality.

AIM: To assess the possibility of embryonic posture evaluation (=feasibility, reproducibility, variation) at rest at 9 weeks' (+0-6 days) gestational age (GA) using four-dimensional ultrasound and virtual reality (VR) techniques. Moreover, it is hypothesized that embryonic posture shows variation at the same time point in an uneventful pregnancy. METHODS: In this explorative prospective cohort study, 23 pregnant women were recruited from the Rotterdam periconceptional cohort. A transvaginal four-dimensional ultrasound examination of 30 min per pregnancy was performed between 9 and 10 weeks' GA. The acquired datasets were offline evaluated longitudinally (i.e. per frame) using VR techniques. RESULTS: The ultrasound data of 16 (70%) out of 23 pregnancies were eligible for evaluation. At rest the analysis of the embryonic posture was feasible and showed a strong (>80%) intraobserver and interobserver reproducibility for most body parts. The majority of the body parts were in similar anatomic positions at rest. However, variations in anatomic positions (e.g. 6% rotated head, 9% laterally bent spine), within and between embryos, were seen at 9 weeks' GA. CONCLUSION: In this unique study, we showed for the first time that embryonic posture measurements at rest can be performed in a reliable way using state-of-the-art four-dimensional ultrasound and VR techniques. Already early in prenatal life there are differences regarding posture within and between embryos.

Effects of an Early Pregnancy Assessment Clinic (EPAC) on the Management of Spontaneous Abortions.

OBJECTIVE: Patients who experience spontaneous abortion often present to the emergency department (ED), which may restrict the physician's recommendations for and the patient's choice of therapy. With support provided by an early pregnancy assessment clinic (EPAC), expectant and medical management may become more feasible options for spontaneous abortion. This study aimed to compare the therapeutic choices before and after the establishment of an EPAC and hypothesized that the proportion of miscarriages treated expectantly or medically would increase. METHODS: We conducted a retrospective cohort study that compared patients presenting to the ED and the EPAC with spontaneous abortion. We excluded patients with hemodynamic instability, complete abortions, ectopic pregnancies, and molar pregnancies. The primary outcome was the initial chosen treatment. The retrospective chart review included demographics, type of spontaneous abortion and management, procedural dictations, ED notes, and EPAC clinic documentation. Secondary end points included wait times, repeat visits, and success rates for the initial treatment option. RESULTS: We reviewed 103 ED and 92 EPAC patient records. Patients in the ED were 1.52 times more likely to choose surgery over expectant or medical management (P = 0.004). Patients in the ED were 1.41 times more likely to have surgery as their final treatment compared with patients in the EPAC (P = 0.006). There were no significant differences in length of stay, number of visits required, or adverse outcomes. CONCLUSION: Our study demonstrates that an EPAC results in more patients choosing and successfully being treated by expectant or medical management for spontaneous abortion.

Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries.

OBJECTIVE: Abortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low- and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety. DATA SOURCES: A systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL. STUDY SELECTION: Criteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and low- or middle-income country status as designated by the World Health Organization. DATA EXTRACTION: Results for effectiveness, safety, acceptability, and qualitative information were assessed. DATA SYNTHESIS: The literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 µg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion. CONCLUSIONS: Mifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.

Very Prolonged Anti-D: Confusion Surrounding Alloimmunization After Extra Rh Immunoglobulin: A Case Report.

BACKGROUND: Rh immunoglobulin (RhIg) is usually detectable a maximum of 12 to 14 weeks after administration. Positive antibodies beyond this time frame suggests alloimmunization. CASE: A woman had three pregnancies over a 6-month period, with two first-trimester losses. She received RhIg in the first pregnancy but not in the second. Two months after the second loss, in her third pregnancy, she received RhIg at week 6 due to first-trimester bleeding. She was subsequently anti-D antibody positive up to week 28 with antibodies too low to titre, leading to confusion about whether alloimmunization had occurred. CONCLUSION: Rh Ig administration led to positive anti-D antibodies lasting 22 weeks, suggesting keeping this differential diagnosis in mind when suspecting alloimmunization with positive antibodies at levels too low to titre.

[Prospective cohort study of fetal nuchal translucency in first-trimester and pregnancy outcome].

Objective: To explore the relationship between fetal nuchal translucency (NT) in the first trimester and pregnancy outcome. Methods: A prospective cohort study was conducted in Nanjjing Drum Tower Hospital from December 2015 to December 2018, 4 958 singleton pregnant women were enrolled to screen fetal ultrasound structure and serology in the first trimester, ultrasound in the second trimester and neonatus physical examination 28 days after birth. According to the results of NT, 167 cases of fetus with increased NT (≥3.0 mm) and 4 791 cases of normal NT were divided, moreover, 86 cases with isolate increased NT and 81 cases of increased NT combined with structural abnormality. The prognosis of fetuses with different NT thickness was analyzed, and the pregnancy outcome of fetuses with isolate increased NT or combined with structural abnormality were analyzed. In the first trimester, if the fetal structure was abnormal or the serological screening result was high risk, the chromosomal microarray analysis (CMA) would be performed by chorionic villus sampling to determine the prenatal diagnosis. Results: (1) The pregnancy outcome for fetus of normal NT: there were 4 791 cases with normal NT. Totally, 4 726 cases with normal NT and no structural abnormalities were screened out in the firsttrimester. In this group, 5 cases of aneuploidies were diagnosed based on high risk of maternal serum biomarkers and 83 cases of structural abnormalities were screened out in the subsequent ultrasound scan and the neonatal examination. Another 65 cases with normal NT present complicated with structural anomalies were screened out in the first trimester and 4 cases were diagnosed as aneuploidies. (2) The pregnancy outcome for fetus of isolate increased NT: 66 (76.7%, 66/86) cases of isolated increased NT were performed CMA, 3 cases were diagnosed as trisomy 21 and terminated pregnancy. Another 4 cases were terminated pregnancy privately without cytogenetic diagnosis. No further anomalies were found in 79 cases till 6 to 21 months postnatally. (3) The pregnancy outcome for fetus of increased NT with structural anomalies: increased NT present with structural anomalies were screened out by detailed anomaly scan in the first trimester and 32 of them were confirmed as aneuploidies. In this group, 70 cases terminated pregnancy, 2 cases had spontaneous miscarriages and 9 cases had liveborns (1 newborn was found ventricular septal defect). (4) The pregnancy outcome for fetus of increased NT with or without structural anomalies: the percentage of aneuploidies in fetuses with isolated increased NT (3.5%, 3/86) was significantly lower than those with structural abnormalities (39.5%,32/81). The healthy survival rate in fetuses with isolated increased NT (91.9%,79/86) was significantly higher than those with structural abnormalities (9.9%, 8/81). Conclusions: A detailed first-trimester anomaly scan could improve prenatal screening efficiency of birth defects. Compared to the fetuses with increased NT combined with structural abnormalities, the healthy survival rate of fetuses with isolated increased NT based on detailed first-trimester anomaly scan is higher and the percentage of fetal aneuploidies is lower.

[Construction and validation of pregnancy risk prediction model for pregnant women with chronic kidney disease].

Objective: To construct the pregnancy risk prediction model of chronic kidney disease (CKD) pregnant women by analyzing their renal function and pregnancy outcome in the first trimester. Method: Totally 313 CKD women with 322 pregnancies who had deliveries in Peking University First Hospital from March 2009 to December 2018 were retrospectively analyzed. The history of kidney disease and renal function in the first trimester were collected, and the relationship between CKD and premature delivery, low birth weight infants, severe preeclampsia and fetal loss were analyzed. Result: Among 322 pregnancies with CKD, 120 (37.3%, 120/322) had adverse pregnancy outcomes. CKD stage, serum creatinine, urea, albumin, hemoglobin, 24-hour urine protein quantity and whether complicated with hypertension were independent predictors of adverse pregnancy outcome. A prediction model logit (P)=2.107+0.255×24-hour urine protein quantitative (g/24-hour)-0.107×albumin (g/L)+1.677×whether complicated with hypertension (1 or 0)+ 0.639×CKD stage was established. The area under curve value of the model was 0.812, the best threshold, sensitivity, specificity and Yoden index were 0.436, 0.658, 0.856 and 0.802, respectively. Conclusion: CKD stage, serum albumin, 24-hour urine protein quantity in the first trimester and hypertension are the main risk factors of adverse pregnancy outcome, which could predict the occurrence of adverse pregnancy outcome of CKD pregnant women and deserve further study.

[Correlation between uterine scar condition and uterine rupture for pregnancy women after previous cesarean section].

Objective: To investigate the relationship between the previous cesarean scar thickness, previous cesarean scar defect and the occurrence of uterine rupture for pregnancy women after previous cesarean section and to predict the occurrence of uterine rupture in the third trimester for pregnancy women after previous cesarean section by analyzing the lower uterine segment (LUS) situation or quantitatively measure LUS myometrium thickness. Methods: A total of 154 pregnant women who have a prior cesarean from January 2015 to March 2016 were selected, all of them regularly did the prenatal examination in the pregnancy period and finally gave birth in hospital. By the transvaginal sonograph, the LUS myometrium thickness (transverse and longitudinal thickness) and the size of the previous cesarean scar defect were measured in the first trimester, the LUS myometrium thickness (longitudinal thickness) and qualitatively analysis LUS condition were measured in the third trimester. They were divided into two groups according to the pregnancy outcome: uterine rupture group (found in the cesarean operation or during the pregnancy) and without uterine rupture group (including the vaginal delivery women and those without uterine rupture in the cesarean operation period). The sensitivity and specificity of LUS myometrium thickness in the first trimester and the qualitative analysis LUS situation, the quantitative measurement of LUS myometrium thickness in the third trimester were compared in the prediction of occurrence of uterine rupture (dehiscence or complete rupture). Results: The group without uterine rupture included 134 women (6 vaginal delivery and 128 cesarean delivery), and the group with uterine rupture included 20 women (all of them cesarean delivery). The LUS myometrium thickness in the third trimester in the group without uterine rupture was (1.6±0.5) mm, and was (1.1±0.7) mm in the uterine rupture group (P= 0.004). There were no significant difference between two groups in the mean value of age, height, weight, the interdelivery interval, the LUS myometrium thickness (transverse and longitudinal thickness) in the first trimester. Qualitative analysis of LUS condition had higher specificity (99%), higher positive predictive value (92%), higher negative predictive value (94%) and slightly lower sensitivity (60%) than quantitative measure of LUS myometrium thickness in predicting uterine rupture. Conclusions: Measurement of the LUS myometrium thickness in the first trimester is helpful for predicting the occurrence of uterine rupture, so it is not necessary to terminate the pregnancy because of the thin LUS or the little prior cesarean scar defect in the first trimester. However it should be paid close attention to the LUS situation during the whole gestation. Qualitatively analyzing LUS situation is more meaningful than quantitatively measuring LUS myometrium thickness in predicting the uterine rupture in the third trimester.

[High level of hemoglobin during the first trimester of pregnancy associated with the risk of gestational diabetes mellitus].

Objective: To explore the relationship between hemoglobin (Hb) level during the first trimester of pregnancy and gestational diabetes mellitus (GDM). Methods: A total of 1 276 participants, who underwent scheduled prenatal examination and normal singleton delivery at the Fifth People's Hospital of Shanghai and Hospital of Intergrated Chinese and Western Medicine in Minhang District, from January 2016 to May 2018 were included. There were 99 cases of GDM (GDM group) and 1 177 cases of normal (control group) pregnant women.Based on the serum Hb level during the first trimester of pregnancy, participants were divided into three groups, 236 cases of low Hb level group (Hb<110 g/L), 868 cases of normal Hb level group (110 g/L≤Hb<130 g/L), and 172 cases of high Hb level group (Hb≥130 g/L). Maternal clinical data were collected, including Hb level during the first trimester of pregnancy, three-point blood glucose (BG) of oral glucose tolerance test (OGTT) and fasting insulin during the second trimester of pregnancy. Homeostasis model assessment of insulin resistance index (HOMA-IR) and homeostasis model assessment of pancreatic ß cell function index (HOMA-ß) were used to evaluate insulin resistance and pancreatic ß cell function. Results: (1) Hb level during the first trimester of pregnancy in GDM group was significantly higher than that in control group [(123±10),(119±11) g/L, P<0.05]. There were no significant difference in gravidity, parity, index of liver and renal function (all P>0.05). (2) Pre-pregnancy body mass index (BMI), 1-hour BG and 2-hour BG of OGTT were significantly increased in the high Hb level group during the first trimester of pregnancy, which were (23±4) kg/m(2), (7.3±2.0) mmol/L, and (6.5±1.4) mmol/L (P<0.05), respectively. The pre-pregnancy BMI, 1-hour BG and 2-hour BG of the normal or low Hb level group were (22±3) kg/m(2), (6.7±1.6) mmol/L, (6.1±1.2) mmol/L; (22±3) kg/m(2), (6.5±1.5) mmol/L, (5.9±1.1) mmol/L, respectively. There were no statistically significant difference in levels of fasting blood glucose, fasting insulin, HOMA-IR and HOMA-ß within 3 groups (all P>0.05). (3) In the high Hb level group, prevalence of pregnancy overweight or obesity and GDM were the highest, which were 37.2%(64/172) and 15.1%(26/172), respectively; the differences were statistically significant (all P<0.05). (4) The serum Hb level in the first trimester was positively related with pre-pregnancy BMI (r=0.130, P<0.05), 1-hour BG (r=0.129, P<0.05), 2-hour BG (r=0.134, P<0.05), fasting insulin (r=0.096, P<0.05), and HOMA-IR (r=0.101, P<0.05).Logistic regression indicated that Hb≥130 g/L during the first trimester of pregnancy was an independent risk factor for GDM (OR=2.799, 95%CI: 1.186-6.604; P<0.05). Conclusion: The high level of Hb (Hb≥130 g/L) during the first trimester of pregnancy is associated with GDM.

[Chromosome abnormality rate and related factors of spontaneous abortion in early pregnancy].

Objective: To investigate chromosome abnormality rate and related factors of spontaneous abortion in early pregnancy. Methods: A total of 831 tissue samples of spontaneous abortion in early pregnancy were collected from June 2015 to August 2018 in the First Affiliated Hospital of Nanjing Medical University. Chromosomal copy number was analyzed by next generation sequencing (NGS). The relationships between chromosome abnormality and maternal age, in vitro fertilization-embryo transfer (IVF-ET) pregnancy, number of previous spontaneous abortions, history of live birth were analyzed by statistical methods. Results: Among 831 tissue samples of spontaneous abortion in early pregnancy, 461 (55.5%, 461/831) were found to have chromosome abnormalities. Maternal age (OR=1.107, 95%CI: 1.070- 1.145) and history of live birth (OR=1.909, 95%CI: 1.182-3.083) were the positive correlative factors of chromosome abnormality. Times of previous spontaneous abortion (OR=0.807, 95%CI: 0.702-0.928) and IVF-ET pregnancy (OR=0.554, 95%CI: 0.404-0.760) were the negative correlative factors of chromosome abnormality. Conclusions: Chromosome abnormality is an important cause of spontaneous abortion in early pregnancy. The rate of chromosome abnormality increases with the increase of maternal age and the history of live birth, and decreases with the increase of number of previous spontaneous abortion and IVF-ET pregnancy.

[Study of genetic etiology in fetuses with severely short limbs in the first and second trimester using whole exome sequencing].

Objective: To investigate pathogenic genes related to the phenotype of fetus with severely short limbs in the first and second trimester by whole exome sequencing (WES). Methods: Thirteen fetuses with severely short limbs detected by ultrasonography in the first and second trimester admitted in Chinese PLA General Hospital from September 2016 to June 2018 were collected. All cases were performed induced abortion, 6 of which were carried out karyotype analysis of amniotic fluid at the same time. WES and copy number variations (CNV) were performed on specimens from fetal tissues after labor induction. The suspected pathogenic mutations were validated by Sanger sequencing reactions. Results: No abnormal karyotypes or pathological CNV were found. In 10 fetuses, pathogenic or possibly pathogenic mutations were detected in the following genes: COL2A1, FGFR3, COL1A1, COL1A2, DYNC2LI1 and TRIP11, all of which were essential to skeletal development. The diagnostic yield of WES in the fetuses with severe short limbs was 10/13. Conclusions: In the first and second trimester, most of the fetuses with extremely short limbs suffer from monogenic diseases. WES is likely to be a valuable diagnostic testing option for the fetuses with severe short limbs.

First Trimester Uterine Rupture, a Rare but Life-Threatening Event: A Case Report.

Uterine rupture often occurs in the third trimester of pregnancy or during labor. Its occurrence in early pregnancy and in the absence of any predisposing factors is very rare. Untimely diagnosis and a low index of suspicion could be life-threatening. Here we report the case of a 29-year-old woman with a history of two previous cesarean sections. An ultrasound report revealed a dead fetus in the abdominal cavity at 14 weeks into the abdominal cavity due to a rupture at the site of the previous cesarean scar. Awareness of probable diagnosis of uterine rupture in a pregnant woman with abdominal pain could be important for timely diagnosis and proper management.

[Analysis for the pregnancy outcome of cystic hygroma fetuses and correlation with increased nuchal translucency in first trimester].

Objective: To analyze prognosis-related risk factors of first trimester cystic hygroma (CH) fetuses in which nuchal translucency (NT) was found to be thickened. Methods: Tolly 216 singleton pregnancies in which fetal NT≥3.0 mm at the 11~13+6 weeks scan accepted invasive prenatal diagnosis in Beijing Gynecology and Obstetrics Hospital, Capital Medical University, from January 2014 to December 2015 were collected. A total of 164 (75.9%, 164/216) single fetuses with complete data were included, they were classified into two groups, namely 'CH' and 'increased NT' which without CH. And 40 pregnancies (24.4%, 40/164) presented with CH group, 124 pregnancies (75.6%, 124/164) were with increased NT group. The chromosome karyotype abnormality, major organ structure malformation and adverse outcome were compared between the two groups. Logistic regression analysis was used to investigate the effect of increased NT thickness, the presence of septa in CH on abnormal karyotype, major congenital anomaly and adverse outcome. Results: (1) The incidence of fetal abnormal karyotype [55.0% (22/40) vs 29.0% (36/124) ], major organ anomalies [45.0% (18/40) vs 25.8% (32/124) ], and adverse outcome [92.5% (37/40) vs 50.8% (63/124) ] were significantly different (all P<0.05) between the CH group and the increased NT group. (2) NT measurement was significantly higher in the CH group than that in the increased NT group (8.32 vs 5.06 mm, P<0.01) . (3) Logistic analysis revealed that NT thickness was the significant risk factor in the prediction of adverse outcome for CH fetuses in first trimester. The risks of chromosomal defect, major congenital anomaly and adverse outcome increased 1.171, 1.192 and 1.913-fold (all P<0.05) with 1.0 mm increased NT thickness, while the presence of septa in CH didn't increase the risks of above (all P>0.05) . Conclusions: The perinatal outcome of CH is poor. The poor outcome of CH is closely attributed to thickened NT, and the presence of septa in CH does not increase the risk of adverse outcome for CH fetuses.

[Analysis of clinical factors on early pregnancy loss during in vitro fertilization-embryo transfer treatment and natural pregnancy].

Objective: To compare differences of clinical factors related to early pregnancy loss between invitro fertilization-embryo transfer (IVF-ET) treatment and natural pegnancy. Methods: A retrospective analysis was performed on the 363 cases of early pregnancy loss between Dec. 2015 to May 2016 in Peking University Third Hospital, during which 173 cases were after IVF-ET treatment (IVF-ET group) , and others were natural pregnancies (natural group) . Results: The average age in IVF-ET group was significantly higher than that in the natural group [ (34.1±4.3) versus (31.8±4.1) years old, P<0.01]. The terminating time of pregnancy loss in IVF-ET group was short than that in the natural group [ (59.8±9.2) versus (69.9±11.1) days, P<0.01]. The incidence of embryo abnormal chromosome in IVF-ET group was significantly lower than that in the natural group [57.2% (99/173) versus 74.2% (141/190) , P<0.01], during which abnormal chromosome numbers were the most common. Conclusions: The pregnancy loss of early pregnancy is mainly caused by chromosome abnormality. The proportion of chromosome abnormality in early pregnancy loss after IVF-ET is not higher than that of natural pregnancy, indicating that there are relatively reliable gametes and embryo safety in IVF treatment.

"Hypothyroidism screening during first trimester of pregnancy".

BACKGROUND: Subclinical hypothyroidism is defined as an elevated thyroid-stimulating hormone level with a normal thyroxin level without signs or symptoms of hypothyroidism. Although it is well accepted that overt hypothyroidism has a deleterious impact on pregnancy, recent studies indicate that subclinical hypothyroidism may affect maternal and fetal health. Studies suggest an association between miscarriage and preterm delivery in euthyroid women positive for anti-peroxidase antibodies and/or anti-thyroglobulin antibodies. A proposal of a new set-point to diagnose SCH was recently published. The aim of this research was to determine the optimal thyroid-stimulating hormone cut-off point to screen for subclinical hypothyroidism in the first trimester of gestation in a population of our clinical area and to determine the diagnostic value of this screening test for detecting anti-thyroid peroxidase antibodies. METHODS: This cross-sectional study determines the cutoff point for SCH screening and evaluates its usefulness to detect TPO Ab using the Receiver Operating Characteristics (ROC) curve. Prevalence of SCH was calculated using as cut-off 2.5 mIU/L, 4 mIU/L, and our TSH 97.5th percentile. The ability to detect positive anti-thyroglobulin antibodies (TG Ab) and anti-thyroid peroxidase antibodies (TPO Ab) in patients with levels of TSH >97.5th percentile was determined by ROC curves. RESULTS: The mean, range and standard deviation of TSH was 2.15 ± 1.34 mIU/L (range 0.03-8.82); FT4 was 1.18 ± 0.13 ng/dL (range 0.94-1.3); TG Ab was 89.87 ± 413.56 IU/mL (range 0.10-4000); and TPO Ab was 21.61 ± 46.27 IU/mL(range 0.10-412.4). The ROC. analysis of the ability of the TSH level to predict the presence of positive TPO Ab found an AUC of 0.563. CONCLUSION: In our population, the TSH cutoff value for gestational SCH screening is 4.7 mIU/L. Using the SEGO recommended 2.5 mIU/L TSH cut-off point, the prevalence of SCH is 37%. Applying the ATA 2017 recommended cutoff point of 4 mIU/L, the prevalence of SCH is 9.6%. Finally, when the cut-off of 4.7 mIU/L (our 97.5th centile) was used, the SCH prevalence is 5%. TSH levels in the first trimester of pregnancy are not useful to detect TPO Ab.

First Trimester Prenatal Care Initiation Among Hispanic Women Along the U.S.-Mexico Border.

Background First trimester prenatal care (FTPNC) is associated with improved birth outcomes. U.S.-Mexico border Hispanic women have lower FTPNC than non-border or non-Hispanic women. This study aimed to identify (1) what demographic, knowledge and care-seeking factors influence FTPNC among Hispanic women in border counties served by five Healthy Start sites, and (2) what FTPNC barriers may be unique to this target population. Healthy Starts work to eliminate disparities in perinatal health in areas with high poverty and poor birth outcomes. Methods 403 Hispanic women of reproductive age in border communities of California, Arizona, New Mexico and Texas were surveyed on knowledge and behaviors related to prenatal care (PNC) and basic demographic information. Chi square analyses and logistic regressions were used to identify important relationships. Results Chi square analyses revealed that primiparous women were significantly less likely to start FTPNC than multiparous women (χ2 = 6.8372, p = 0.0089). Women with accurate knowledge about FTPNC were more likely to obtain FTPNC (χ2 = 29.280, p < .001) and more likely to have seen a doctor within the past year (χ2 = 5.550, p = .018). Logistic regression confirmed that multiparity was associated with FTPNC and also that living in Texas was negatively associated with FTPNC (R2 = 0.066, F(9,340) = 2.662, p = .005). Among 27 women with non-FTPNC, barriers included late pregnancy recognition (n = 19) and no medical insurance (n = 5). Conclusions This study supports research that first time pregnancies have lower FTPNC, and demonstrated a strong association between delayed PNC and late pregnancy recognition. Strengthened investments in preconception planning could improve FTPNC in this population.

[Retrospective analysis of outcomes of selectively or spontaneously reduced multiple pregnancies out of 6 917 in vitro fertilization-embryo transfer pregnancy cycles].

Objective: To analyze the effects of fetal reduction in early pregnancy on obstetric and neonatal outcomes of spontaneously or selectively reduced multiple pregnancies produced by in vitro fertilization-embryo transfer (IVF-ET). Methods: Retrospective study of 6 917 clinical pregnancies from IVF-ET cycles, including 754 multiple pregnancies divided into two groups according to the remaining fetus number: reduced singleton group (n=599) and reduced twin group (n=155); and maternal and neonatal outcomes of two groups were compared to primary singleton group (n=3 589) and primary twin group (n=2 574). Results: The rate of pregnancy complication [9.85%(59/599) versus 6.21%(223/3 589)], preterm birth [19.37%(116/599) versus 10.73%(385/3 589)], low birth weight [9.71%(56/577) versus 4.57% (152/3 324)], perinatal death [0.69%(4/577) versus 0.12%(4/3 324)] and malformation [2.95%(17/577) versus 1.02%(34/3 324)] in reduced singleton group were significantly higher than those in primary singleton group (all P<0.01). There were no significant differences between reduced twin group and primary twin group (all P>0.05). In reduced singleton group, birth defect rate was 2.95%, which was higher than those of the other three groups (P<0.05), in this group spontaneous pregnancy reduction accounted for 89.3% (535/599). Conclusions: (1) The rate of pregnancy complication, preterm birth, low birth weight, perinatal death and malformation in reduced singleton group are still higher than primary singletons, suggesting embryo reduction only is a compensated method in multiple pregnancies. Limiting the number of embryos transferred is the essential solution. (2) The rate of birth defect in spontaneous pregnancy reduction group is higher, so prenatal examination should be reinforced in this group.